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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610100
Report Date: 12/07/2021
Date Signed: 12/07/2021 05:08:51 PM

Document Has Been Signed on 12/07/2021 05:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:HAPPY PLACE ELDER CAREFACILITY NUMBER:
197610100
ADMINISTRATOR:JAVIER, HERMAN B.FACILITY TYPE:
740
ADDRESS:23609 DAISETTA DRIVETELEPHONE:
(661) 505-7600
CITY:NEWHALLSTATE: CAZIP CODE:
91321
CAPACITY: 6CENSUS: DATE:
12/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:27 AM
MET WITH:AdminTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Abeye Duguma met with the Administrator Herman Javier for a One (1) Year Required - Infection Control visit for this facility. LPA explained the reason for the visit. A tour of the physical plant was conducted at 10:30am and the following was noted:
There is one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask upon entrance and during the visit. Signs to wear a mask and other COVID 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated outdoor visitors' area located in the backyard. The facility has sufficient stock of PPE in a storage cabinet located in the hallway. The facility has seven (07) bedrooms total of which six (06) are used for residents and three (03) bathrooms for both residents and staff. The facility is fire cleared for six (06) non-ambulatory and a hospice waiver for four (04). The facility is currently occupying five (05) ambulatory residents and one (01) non-ambulatory resident. The backyard of the facility has outdoor furniture, with a covered shaded area for clients. The facility has a swimming pool with a locked gate. The garage is currently being used as laundry/storage room. Laundry detergents, cleaning agents and other toxins are stored in a locked cabinet in the garage. Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests.
(continued on LIC 809-C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HAPPY PLACE ELDER CARE
FACILITY NUMBER: 197610100
VISIT DATE: 12/07/2021
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Knives and sharps are observed to be locked in a kitchen drawer inaccessible to residents. Living and dining room furniture were also checked. The living room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 72°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located in the kitchen and observed to be purchased 10/2020. Staff room was observed to be locked and located near the kitchen area. No medications are observed in the staff room. The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are well lit. Clients have enough personal hygiene product, some of which are provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 118.9°F. Towels and washcloths are not shared. There was enough clean linen available in the hallway cabinet. Medications: LPA observed medication cabinet to be locked and inaccessible to residents, located in the hallway cabinet near the kitchen area. There is a complete first aid kit located inside the cabinet at the end of the hallway.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021
LIC809 (FAS) - (06/04)
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